Clinical leadership and quality in district health boards

DISTRICT HEALTH BOARD ORGANISATION 5.1 Organisational overview 5.2 Organisation of clinical services 5.3 Devolution of clinical service accountability 5.4 Organisation of nursing ser

CLINICAL LEADERSHIP AND QUALITY IN DISTRICT HEALTH BOARDS IN NEW

ZEALAND

Report commissioned by the Clinical Leaders Association of New

Zealand for the Ministry of Health

Laurence Malcolm Professor Emeritus and Consultant

Aotearoa Health

Lyn Wright, Consultant Aotearoa Health

Pauline Barnett, Senior Lecturer

Department of Public Health and General Practice

Christchurch School of Medicine

Chris Hendry, Postgraduate Midwifery Lecturer Health Service Development Consultant

January 2002

PREFACE AND ACKNOWLEDGEMENTS

We are grateful to the many organisations and individuals which have assisted in this project These include Clinical Leaders Association of New Zealand (CLANZ) for

encouragement and financial support to enable the project to be undertaken We are also grateful to the participating district health boards for providing information and

commenting on the drafts of their sections and the full report

Address for comment, laurence.malcolm@cyberxpress.co.nz

Phone 03 3299084

Disclaimer

The views expressed in this literature review do not reflect those of CLANZ or the Ministry of Health

3.3 DHB establishment and structure

3.4 Progress with DHB development

5 DISTRICT HEALTH BOARD ORGANISATION

5.1 Organisational overview

5.2 Organisation of clinical services

5.3 Devolution of clinical service accountability

5.4 Organisation of nursing services

6 QUALITY INITIATIVES IN DHBs

6.1 Organisational support for quality improvement

6.2 Quality initiatives in DHBs

8 CLINICAL ADVISORY FUNCTIONS

9.1 Education and training programmes

9.2 The need for clinical leadership development

10 CLINICAL GOVERNANCE - THE ROLE OF CLINICAL

LEADERSHIP

11 DISCUSSION:QUALITY DEVELOPMENTS IN DHBS

11.1 Information sources: tensions and limitations

11.2 Devolution of decision making

11.3 Towards a successful nursing organisation

11.4 Review of quality developments –incentives, achievements 11.5 Clinical leadership – a new role for clinicians

Appendix 1 A review and analysis of clinical leadership/governance in addressing issues

of quality the New Zealand health system

Appendix 2 District Health Board Reports

Background

1 District health boards (DHBs) are the centrepiece of the Labour/Alliance

government's health reforms They bring together, in one organisation, almost all the funding and provision of health and disability services for their defined populations Their primary goal, within the New Zealand Health Strategy, is to achieve better health outcomes for their district populations

2 As part of the international movement to achieve better clinical quality outcomes there is an expectation and requirement that DHBs build an integrated, quality driven culture There is emerging evidence of significant quality initiatives and of the

important role which clinical leadership is playing in their promotion and

implementation Clinical leadership may be defined as leadership by clinicians of clinicians

3 However almost no studies have been undertaken to document these quality

initiatives, to identify the key drivers and the extent of progress This project,

scanning clinical leadership and quality initiatives in selected to DHBs, seeks to fill this gap It was commissioned by the Clinical Leaders Association of New Zealand (CLANZ) as part of its contract with the Ministry of Health,

4 It is the third of a ‘trilogy’ of studies, the first examining quality initiatives and

clinical governance internationally, the second a parallel study of clinical leadership and quality developments in primary care organisations (PCOs)

5 The overall aim of this study was to document and analyse organisational

arrangements within 10 selected DHBs, the role of clinical leadership within the changing arrangements, clinical quality initiatives and processes, and to seek views

on the use and meaning of the term clinical governance

Development of DHBs

6 Clinical leadership has evolved over the last 20 years within a framework of service groupings based upon clinical specialties, medical, surgical, child health, etc This development has seen increasing involvement of clinicians in management and a new form of collective professional accountability, replacing the traditional individual autonomy of the medical profession

7 Progress towards this accountability was set back in some situations with the ‘clash of cultures’ experienced during the commercially driven reforms of the 1990s As a consequence there were serious effects upon clinical quality from which recovery is still in progress

8 In line with the New Zealand Health Strategy DHBs provide a new and important opportunity for clinical leadership to work with management to achieve quality improvements These include new structures and processes, progressive devolution to

clinical services for defined responsibilities and building new and integrating

relationships especially between primary and secondary care

Methods and sources of information

9 In order to achieve the objectives of this project all DHBs were contacted and invited

to comment and participate Ten DHBs was selected representing a broad range of populations and settings and were personally visited for discussions regarding the project

10 There was full co-operation in setting up interviews, providing information including

a ‘signed off’ report Reports upon which the following overview is based were received from; Northland, Auckland, Counties Manakau, Waikato, Lakes, Hutt Valley, Capital and Coast, Nelson/Marlborough, Canterbury and Otago

DHB organisation

11 It was consistently stated that accountability for clinical quality was located within the clinical divisions An understanding was therefore needed of the organisation of clinical services within the DHB provider side

12 The most common organisational model, under the CEO, is a COO or general

manager of the provider side Reporting to the CEO or COO is a chief medical

officer/advisor (CMO/A) and chief nursing officer/advisor (CNO/A) or equivalent These were seen in most DHBs to be key positions, particularly in the promotion of clinical quality throughout the organisation

13 Under the CEO or equivalent, all DHBs had some form of clinical organisation, both major clinical divisions and clinical subdivisions However the number and

composition varied widely

14 In almost all situations there is a strong emphasis upon a partnership, either actual or developing, between clinical leaders/directors and management Accountability for both quality and cost is seen to be a joint activity to which both managers and

clinicians are ‘signed up’

15 There is increasing devolution of decision-making to clinical services for both clinical and financial accountability However the scope and implementation of devolution varies widely Direct service expenditure, including nursing, is largely devolved but only in a minority of DHBs is there devolution of clinical support services and

overheads

16 Nursing budgets are largely devolved to clinical service groupings, thus removing the CNO/A from direct nursing management Only in a minority of DHBs is a nursing director partnered with the clinical (medical) director and manager There is much variability and consequent uncertainty in the way nursing services are being

organised The pros and cons of a more devolved nursing service are reviewed

Quality initiatives and achievements in DHBs

17 Most DHBs have now established, or are establishing, formal organisational support systems for quality improvements including; clinical boards/groups, clinical

improvement/advisory/executive committees and associated quality and risk

managers Some DHBs are including the non-government sector in quality

improvement strategies

18 While all DHBs have quality plan requirements as part of their contract only five mentioned these There is increasing commitment to, and implementation of, quality and risk management programmes, accreditation, clinical audit, credentialling and developing quality frameworks Integration of clinical and financial management is seen to be an important part of quality

19 A wide range of quality achievements were reported by DHBs These included;

! changes in the organisational culture, eg greater openness and moves towards a culture of safety

! a growing partnership between clinicians and management including a move away from a strictly ‘business’ approach to quality

! integrating previously disparate quality efforts into single coherent quality system

! implementation of an effective adverse incident system, working towards

accreditation, credentialling and clinical audit

! appointment of staff dedicated to quality

20 Factors that facilitated these achievements included;

! experience of accreditation, appointment of specific staff to be responsible for quality, the ability to provide resource tools and incentives, the integration of clinical and financial management, adverse events giving greater attention to quality

21 On the other hand progress was hindered by;

! resource constraints, inadequate time for clinicians to participate, shortage of leadership skills and past conflicts leading to mistrust between clinicians in

management

Clinical advisory functions

22 The establishment of CMO/A and CNO/A positions at the senior executive level of the DHB on the provider side, has led to a new avenue for clinical advice These positions are also seen to be important in providing clinical leadership for quality improvements in DHBs

23 Medical advice and participation is increasing with the involvement of clinical staff at leadership level in management This is resulting in a diminishing need for medical and other staff associations However there is still a sense of disempowerment

among some clinicians, aggravated by continuing and increasing funding shortages

Clinical governance

Overview and reservations

25 Reservations need to be expressed about the nature and quality of information drawn upon Funding and time constraints precluded a more detailed review The views presented may not be those of others in the organisation, including of clinicians generally Perceptions of relationships, and progress with quality initiatives, may vary widely between different levels within DHBs

26 Nevertheless the views from the top, including of CEOs and other key people are important They represent a commitment, to if not actual achievements, in quality and relationships A more detailed review is needed of the actual roles and

responsibilities of key leaders, both clinical and management and perceptions from other levels within the DHBs, to gain a better picture of progress with quality

28 There are continuing uncertainties about the devolution of nursing budgets and

management to service groupings Advantages include nurses becoming recognised

as full members of health care teams and the flexibililty of including nursing in the overall clinical budget Disadvantages include limiting flexibility in the overall use

of the nursing workforce and possible subservience of nursing skills and perspectives

to medical and management interests

29 These disadvantages may be minimised with a clear leadership role from the CNO/A, appointment of nursing directors to full partnership in service management, the use of nurse consultants working with service divisions and after regular hours nursing distribution coming under the CNO/A

Organising for quality and sharing experience

30 It is clear that all DHBs are making significant efforts to improve clinical quality and have made important progress However there is continuing uncertainty about the best forms of structuring quality processes and how they should be organised,

managed and funded

31 Despite these initiatives and emerging achievements there is a remarkable lack of sharing of this experience and the lessons learnt Relatively little appears to have been done to document quality achievements in DHBs, either by DHBs or national bodies There is a serious lack of evaluation in the New Zealand health ‘culture’

Clinical leadership - a new role for clinicians

32 This review has noted the growing importance of clinical leadership as a critical factor in promoting clinical quality It has also noted that clinical leadership may be found at three levels; executive ie CMO/A and CNO/A bringing a medical, nursing and broader clinical perspective into top executive decision-making

33 Secondly clinical leadership is found at a broad service level where it is significant and demanding At the third subservice level clinical leadership may be less

demanding and less developed A key feature of clinical leadership at all levels is the need to maintain a respected and valued relationship with ‘rank-and-file’ colleagues

Towards a convergence of governance/management and clinical cultures

34 In almost all DHBs there is evidence of an intention to build a partnership between governance/management and clinical cultures Progress with this partnership is dependent upon a shift on the part of both cultures A successful partnership will be based upon common goals, a commitment of both parties to clinical and financial accountability and to better health outcomes for patients and communities

35 A convergence is also needed within clinical cultures, ie between disciplines, primary and secondary care and personal and disability care Important lessons in developing this convergence, including accountability for quality and cost, can be drawn from primary care

Building a new leadership culture

36 Despite the wide range of quality initiatives being implemented there is a remarkable lack of sharing of the experience being gained It is clear from the study that there is

a need for a national research, development and evaluation strategy for clinical leadership development, including learning from and building on this experience

37 Building a new leadership culture, not only within the DHB system but also in

primary care, would appear to be a critical factor in the success of DHBs It would assist in bringing together the currently divergent cultures of primary and secondary care, personal, public health and disability and of different disciplines

2 INTRODUCTION

2.2 Factors leading to this study

District health boards (DHBs) are the centrepiece of the Labour/Alliance government's health reforms Established in December 2000 they bring together, in one organisation, almost all funding and provision of health and disability services for their defined populations Within the framework of the New Zealand Health Strategy the primary goal

of the DHB system is to achieve better health outcomes for populations of DHB districts DHBs replaced the former system of separate purchasers and providers Although all purchasing functions were integrated under one funder, a commercial focus led to a fragmented provider system In some situations it also resulted in a conflict of goals between governance and management cultures on one hand and clinical cultures on the other This conflict had serious adverse consequences for clinical quality, as will be discussed further below

DHBs are a fundamental contrast to the system they are replacing There is a strong emphasis upon integration of hospital and community care, of primary and secondary care and personal, public health and disability support services Anecdotal evidence has been emerging that the new system is building relationships of a kind which are likely be much more successful in achieving a quality, outcome focused culture There is increasing evidence of the important role which clinical leadership is playing in building new accountability arrangements in this culture Clinical leadership is defined in this review as leadership by clinicians of clinicians

Concerns about clinical quality in health service organisations and attempts to improve quality have become an international movement Major initiatives, such as quality committees, credentialling and a system of reportable events, have been established within DHBs to promote clinical quality Clinical leadership plays an important part in such initiatives

There have been major recent initiatives to improve quality within the New Zealand health system These have been reviewed in Wright et al (2001) A bibliography of published reports and discussion documents is attached The National Health Committee has just produced a discussion document Safe Systems Supporting Safe Care (National Health Committee, 2001) The Government is currently seeking feedback on a discussion paper ‘Quality Improvement Strategy for Public Hospitals’(2001)

Despite these important developments almost no studies have been undertaken to:

! specifically document and analyse these quality initiatives

! identify key drivers

! determine the extent of progress in quality initiatives

2.2 This project

This project scanning clinical leadership and quality initiatives in selected DHBs was commissioned by the Clinical Leaders Association of New Zealand (CLANZ) It is one

The overall aim of this study was to:

! document and analyse the organisational arrangements within 10 selected DHBs

! document the role of clinical leadership within the changing arrangements and the clinical quality initiatives and processes

! seek views on the use and meaning of the term clinical governance

More specific objectives were to review and report on:

! the background, development and organisation within each DHB

! the range of quality initiatives being implemented

! the role of clinical leadership in initiating and driving quality

! the main achievements in quality and the associated facilitating and limiting factors

! education and training programmes to promote quality

! the extent to which clinical governance, either formally or informally, is being developed within DHBs

of 1988 and the implementation of general management at both top management and service level

Table 3.1 Key events/processes and associated outcomes in the evolution of clinical

leadership in the public secondary care sector New Zealand

1975-1988 Traditional hierarchies of medicine,

nursing and administration Lack of service integration and accountability

1980 Formation of the New Zealand

College of Community Medicine

Integration of medical leadership functions and a new training programme

1983 Area Health Boards Act Moves towards leadership and service integration

in a single entity

1988 State Sector Act General management at both top and service

level, leadership integration

1989 Health Services Management

Development Unit (HSMDU) formed

Integrated national multi-disciplinary leadership development, moves towards service management

1991-96 Commercially driven reforms Rise of commercial leadership and devaluing of

clinical leadership, conflict of goals/cultures in Crown Health Enterprises (CHEs) and the sector generally, but growth of primary care leadership 1996-1999 ‘Reform of the reforms’ and moves

towards a more collaborative system

Some convergence in leadership with emergence

of clinical leaders in some HHSs but continuing conflict of goals between divided sectors

2000-2001 Labour government reforms,

national health strategy with national health goals, DHBs as integrating entities

Common goals within the sector, explicit valuing

of clinical leadership, both primary and secondary, moves to devolve quality and cost accountability to clinical groupings, emergence of clinical governance as a key quality strategy

Leadership at the clinical level has evolved largely within a framework of service groupings based upon clinical specialties, eg medicine, surgery, mental health, child health and primary care, etc (Malcolm and Barnett, 1994) Progress towards devolution to these groupings was being achieved through area health boards during their brief existence from the late 1980s to 1992

An important development, which did much to progress a more integrated learning culture

in area health boards, was the formation of the Health Services Management Development Unit (HSMDU) in 1989 This brought together, within a learning environment, top and middle managers from boards and the Department of Health to share experiences, to

3.2 The 1990s reforms

A significant setback to these trends occurred as a consequence of the reforms of the early 1990s The government appointed commercially-focused CHE boards and with the expectation that they be successful businesses and achieve returns on the shareholders (government’s) assets (Malcolm and Barnett, 1994) Boards in turn appointed chief executive officers (CEOs) from the business sector often with little understanding of the

‘business of health’

An MBA became the preferred qualification for senior management appointments HSMDU was disbanded on the grounds that commercially driven incentives would support management development activities, an assumption that proved to be flawed Commercial sensitivity reduced collaboration and sharing between CHEs

In many cases this commercial focus led to a significant conflict with clinicians whose primary goals were better patient outcomes (Hornblow, 1997) The subsequent clash of commercial and professional cultures led, in many cases, to progress in clinical leadership being sidelined The most public expression of this clash was in Canterbury Health, leading to the Stent investigation reported in 1998 (Health and Disability Commissioner, 1998; Foate et al 1999)

This conflict was exacerbated by the funding arrangements of Regional Health Authorities/HFA The conflicting mix of fee-for-service and capped budgets reduced incentives for managers to maximise the use of shareholders’ assets For clinicians there was little incentive or opportunity to become involved in the management of clinical activity Those who did were seen to be taking a ‘soft line’ with management Following the 1996 election CHEs were restructured into Hospital and Health Services (HHS) and the commercial pressures somewhat modified

There was some progress towards clinical leadership development in the Hospital and Health Services, but there was little clarity of goals within HHSs and significant conflict

of goals between clinicians and commercially-focused boards remained

The new DHB system presents an important opportunity for clinical leadership Key features in this new situation are:

! A set of common goals, as specified in the New Zealand Health Strategy, including a greater focus upon health outcomes, which could unite boards, management and clinicians in a common endeavour

! A clear commitment by government to building a collaborative health system and to bring all components together, government and non-government, primary and secondary, health and disability, public and personal

! Moves by boards and management in many DHBs to work more closely with clinicians and to devolve decision-making relating to quality and cost to clinical groupings

This project has sought to explore these features in 10 DHBs

3.3 DHB establishment and structure

The New Zealand Health Strategy, announced by the government in 2000, strongly emphasises health system goals, equity in access, capped population-based funding and the decentralisation of operational decision-making to DHBs (Minister of Health, 2000) There

is a full commitment to integration The government has stressed accountability at all levels including the accountability of clinicians for the quality of the health care they provide

At the governance level the government has specified through legislation that DHBs have

a mix of elected and appointed members Three advisory committees are required:

! hospitals

! primary and community services

! disability support services

However, each DHB can decide on its own organisational structure Most DHBs have decided to operate a separate contracting/funding section under a general manager, reporting to the CEO, and the continuation of the provider side under a chief operating officer (COO) also reporting to the CEO

Some DHBs have indicated an intention to move beyond this interim structure Northland for example has already moved to establish two basic divisions — primary and secondary care The general manager primary care is responsible for overall leadership and strategic planning of the whole primary health care sector, both government and non-government

3.4 Progress with DHB development

Since their formation there has been steady progress with DHB development This includes the establishment of governance structures and committees, progressive devolution of funding for defined responsibilities and initiation of strategic planning functions Also, for most DHBs, it has meant the development of new relationships and partnerships, including with primary care

However progress has been restricted by severe financial limitations with many DHBs expecting to increase their debt by borrowing to cover their operations for the current financial year These restrictions have raised anxieties amongst clinical staff and may have interfered with progress towards the developing partnerships between clinicians and management As will be discussed later these constraints may have placed clinical leaders

in a more difficult position in attempting to build these partnerships

In order to achieve the objectives outlined in section 2.2 above, a detailed plan was prepared by the study group A background statement (Appendix 1) was prepared and sent to all DHBs inviting comment and participation A relatively low level of response was received from this initial contact

It was decided that 10 DHBs would be approached individually and invited to participate through personal discussions and visits A list of topics considered important to achieve the objectives was prepared and presented to DHB management in the course of face to face discussions Discussions almost always included the CEO, COO, chief medical officer/advisor, chief nursing officer/advisor and the quality manager

In many cases discussions were taped as were follow-up telephone interviews with key informants from each DHB Documents were requested including annual reports, strategic and quality plans and other relevant information Web-sites were also visited where available Draft reports were prepared and sent back to nominated individual(s) for additions or amendments and subsequent ‘signing off’

The DHBs visited are as follows Reports relating to individual DHBs are contained in Appendix 2

The information presented in the following sections, whether in the text or in the tables,

is indicative rather than comprehensive The absence of information on a particular topic does not necessarily mean that a DHB is not undertaking work in the area Alternatively, discussion of related work across a number of DHBs does not imply uniformity in provision Ultimately the material presented is only as good as the information provided

In a study which is a “scan” the information, by its very nature, can only be indicative

The following discussion highlights that in some DHBs there is continuing review of organisational arrangements There is also continuing uncertainty and hence lack of clarity in clinical services organisation Perceptions of clinicians and even clinical leaders appear to differ from those presented by top management, in some situations this difference is quite marked It is important to note, as will be discussed later, that the extent to which real clinical decision-making has been devolved to clinical groupings is dependent both upon the willingness of management to devolve and the acceptance of devolution by clinicians

Table 5.1 presents an overview of the clinical organisational arrangements in the 10 DHBs The most common organisational model is, under the CEO, a COO or general manager for the provider side In Hutt Valley DHB there were two basic divisions under the CEO primary and secondary each with a general manager Northland had progressed even further with a general manager for primary and secondary care but with the general manager primary care being responsible for overall leadership of the diverse and fragmented primary care sector, both government and non government, including the rural hospitals

Reporting to the CEO in all the DHBs surveyed except Canterbury, was a chief medical officer/advisor (CMO/A) and chief nursing officer/advisor (CNO/A) or equivalent These were seen to be important positions for the promotion of clinical quality throughout the organisation The CMOs/As had a key medical leadership role that was only partly executive In many cases it involved a continuing clinical role seen to be important in maintaining credible relationships with clinical staff

In a number of cases these were relatively recent appointments and were seen to be part

of the recovery from the former system which had devalued this form of clinical leadership CNOs/As also played a critical role especially with the devolution of nursing

to clinical groupings This is further discussed below

5.2 Organisation of clinical services

Under the COO, or equivalent, all DHBs had some form of clinical organisation, both to major clinical divisions and clinical subdivisions The number of major clinical divisions varied from three in Northland to 11 in Otago In Canterbury DHB this is still under discussion, although has been well-established for a number of years in the former Healthlink South HHS

Northland CEO and GMs primary

and secondary care CMA and DON 3 secondary divisions with group managers partnered with 13 clinical directors for each speciality Yes in primary care Auckland CEO and COO CMO(PT) and DON Clinical leaders in partnership with general managers Clinical directors in

partnership with service managers

In new hospital plan

Counties-Manakau

Chair Clinical Board

8 clinical divisions GM in partnership with clinical medical director and clinical nurse director

Clinical heads in partnership with clinical nurse leaders and service managers

No

Waikato CEO and COO CMA and DON Mental Health – clinical directors and service managers in

partnership, Community Services – service managers in liason with clinical directors, Waikato Hospital – 7 clinical groupings with service managers and clinical unit leaders in partnership

Clinical director Yes

Lakes CEO and providers GM MD(PT) and DON 5 clinical divisions with medical HOD and clinical nurse

Medical HODs and clinical nurse managers

Regional service managers for mental health, intellectual disability and public health

Canterbury CEO and COO None Current system of clinical directors under discussion -

partnership of general manager and clinical director in mental health and older persons health

Under discussion No

Otago CEO and COO CMO and CNO 15 clinical practice groups –clinical leader in partnership

Abbreviations: CEO chief executive officer, COO chief operating officer, GM general manager, CMO/CMA chief medical officer/adviser (PT part time clinical), CNO/A chief nursing officer/adviser,

CNO/A chief nursing officer/adviser, DONP director of nursing practice, DONM director of nursing and midwifery HOD head of department, SM service manager, CUL clinical unit leader, CD Clinoical

director

Most clinical divisions follow a pattern of surgical, medical, child health, women's health, mental health, etc In larger centres there is the usual range of clinical subdivisions of medical and surgical services, eg cardiology, renal, orthopaedics, urology Others such as Otago have a complex mix of service or specialty subdivisions

A variety of disciplinary relationships are found at both service and sub-service level In

a number of situations the medical clinical director or leader is partnered with a general

or service manager and nurse director In other situations nursing is not seen to be an equal partner but is involved in other ways eg through nurse consultant participation

In almost all cases there is a strong emphasis upon a partnership, either actual or developing, between clinical leaders/directors and management Accountability for both quality and cost is seen to be a joint activity to which both managers and clinicians are

‘signed up’

In many DHBs, where there are multiple hospital sites, the service organisation cuts across hospital campuses or, as in the case of Auckland, is planned to do so in the new hospital system Only in Canterbury is there a continuing commitment to a hospital-based system of clinical organisation The integration of hospital services across multiple campuses is an important development as it facilitates a more population-based approach

to service delivery

5.3 Devolution of clinical service accountability

The term devolution has been used in this study in the sense that it is beginning to be commonly used within the New Zealand health system It applies to the delegation by top management of decision-making to clinical service groupings for both clinical and financial accountability However, this accountability is quite variable in its content ranging from only direct service costs to the full range of clinical support services and overheads As indicated elsewhere promoting clinical quality is dependent upon the integration of clinical with financial accountability

Table 5.2 presents a summarised overview of the devolution of decision-making to service and subservice groupings within DHBs In almost all cases there is complete devolution of nursing services to service groupings with these services coming under the management of the service-based system They implications of this will be further discussed below

In a minority of DHBs devolution includes the funding of clinical support services, eg laboratory, radiology, etc which are purchased from clinical service budgets Some DHBs are considering the inclusion of these within service budgets Half of the DHBs include some form of overhead expenditure in service budgets

The extent to which this accountability of clinical directors is functioning effectively varies both between and within DHBs In general, devolution appears to be working effectively at the service level but perhaps less so at a sub-service level Some DHBs mentioned that there had been a retreat from clinical participation as a consequence of the current serious budgetary restrictions Successful devolution also depends upon the prevailing culture within an organisation and, as will be discussed later, the extent of

Counties Manakau To service and

subservice levels

Complete No – being worked on No – being worked on Good at service but less at

subservice Waikato To service and being

considered for subservices

Hutt Valley To services and

subservices

Capital and Coast To service and

subservice levels

Canterbury Only significant in Mental

and Older Persons Health

Otago To clinical practice

groups but not subgroups

recovery from damage done during the commercialisation era and the build up of trust

between clinicians and management

5.4 Organisation of nursing services

Nursing is the largest single workforce within DHBs Table 5.3 summarises the

organisation of nursing services, including nursing involvement at executive level, on

the provider side and participation in clinical advisory boards/committees Table 5.3

also summarises the devolution of nursing services within service budgets and

indicates whether a nurse is part of the management partnership within service

groupings

A DON or equivalent is found in eight of the 10 DHBs Nelson Marlborough has a

divided system because of its geography with a nurse advisor in each setting Only

Canterbury does not have a DON at the top executive level on the provider side

There is a mixed pattern of devolution of nursing services management of the budget

for nursing services to service groupings The predominant pattern is complete

devolution in six DHBs Devolution is being proposed in Canterbury, is mixed in

Waikato and being reviewed in Lakes However associated with this devolution is

limited nursing partnership in the clinical management team with nurse directors at

service level only in Counties Manakau and Lakes, although being considered in other

Yes Complete Being considered

Counties Manakau DONP Yes Complete Clinical nurse directors

reviewed Nurse/midwife consultants and clinical

nurse/midwife leaders Hutt Valley CAN Secondary

Canterbury Hospital only Yes Only in some services Being reviewed

Otago CNO Yes Complete No but nurse consultants

Abbreviations:CNO/A chief nursing officer/adviser, DONP director of nursing practice, DONM director of nursing and

midwifery

It will be obvious from Table 5.3 there is still much variability and uncertainty in the

way nursing services are being organised Devolution of nursing budgets to service

groupings is resulting in radical change in the roles and responsibilities of the DON,

or equivalent, at the top executive level There is a continuing trend away from the

classical centralised model of a nursing hierarchy in which a DON has full control

over nursing budgets and services throughout the organisation

The DON role is hence changing from executive management of the whole nursing workforce to a new leadership role The DON is responsible for professional nursing development, participating in appointments of nurses to key positions and may be using nursing consultants working at the service level to foster the development of quality nursing practice Another issue concerning some DONs is the need to consider the extension of nursing leadership to be inclusive of DHB wide functions, both the provider and contracting sides

Although devolution has advantages it may have a serious downside Of considerable concern to nurses and others seeking to build an effective team at the service level is the way in which nursing management is secured at this level Devolution may reduce efficient management of the overall nursing workforce to cover patient acuity particularly in the acute hospital setting These problems have become more urgent with the current shortage of the nursing workforce and higher nursing turnover The pros and cons, and related implications of a more devolved nursing service, will

be discussed later in section 11

6.1 Organisational support for quality improvement

Table 6.1 provides shows details of the organisational support for quality improvement identified by the 10 DHBs in this study Five of the DHBs, Auckland, Counties-Manukau, Waikato, Lakes and Nelson-Marlborough, indicated that they are reviewing their current situation and planning to make changes to the current organisational support In general DHBs either had in place, or were considering the implementation of, a single integrated quality system Where these systems were being considered they appeared to incorporate previously disparate quality components

Seven of the 10 DHBs had either put in place or were planning to implement an over- arching board or committee with responsibility for either quality alone or quality among other things Those DHBs without any such body were Lakes, which is currently evolving a new quality structure to include this, Nelson-Marlborough and Hutt DHB, the latter having four committees with a focus on quality In the majority

of DHBs these committees relate to the provider side of DHB business Only Auckland appeared to have a wider quality focusing It was setting up a Population Funding Effectiveness Council with responsibility for addressing quality issues on its funding side

The membership of these over-arching committees generally included clinical directors, senior executive staff eg CEO, COO plus CMO/A and DNO/A or equivalent, where they existed Some DHBs had representatives from nursing, midwifery, allied health staff, cultural advisers and, in two places, general practitioner input (Hutt and Counties Manakau) As noted above, seven of the 10 DHBs in the study also employed staff with specific quality responsibilities These ranged from dispersed junior staff, through a registrar employed specifically for clinical audit, to senior level Quality and Risk Managers

The overall picture is one of DHBs revisiting their previous quality practices in the light of:

! the demands of the transition from HHS to DHB status

! the growing external demands and attention to quality in health care

This latter factor reflects a growing interest in the principles of clinical governance, a heightened awareness of quality issues arising from participation in accreditation, as well as the adverse incident experiences of Northland, Tairawhiti and elsewhere

6.2 Quality initiatives in DHBs

Nine DHBs, as shown in Table 6.2, were undertaking credentialling programmes In some such as Auckland and Counties Manakau this was well advanced Lakes, Northland, Capital and Coast were in the early stages of developing their credentialling programme Nelson-Marlborough had successfully completed credentialling in three of its departments and established a Credentialling Committee

23

Table 6.1 Organisational support for quality improvement

District Health Board Proposed Operating Description

- Members: clinical directors, Secondary Care GM, CMA, DON, CEO, Maori Director

- Role – general forum for provider arm, reviewing clinical policies, quality one focus among many

review

! Provider arm – Quality and Safety Manager reporting to COO, Clinical Quality Council (existing) being expanded to cover all aspects of

clinical quality management, membership may become expertise rather than representative based Multidisciplinary quality committees at hospital and clinical unit level

! Funding arm – Population Funding Effectiveness Council to address quality issues

- Members: Clinical Board Facilitator, COO, CMO, clinical directors, DONP, representatives of nursing, midwifery and allied health,

cultural advisers

- Roles/responsibilities: wide range of quality improvement activities eg vision/ values, policies, guidelines, etc

- Clinical Quality Improvement Committee to assist the Clinical Board

! Clinical Facilitator to assist the Clinical Board chairman Waikato # # ! Executive Clinical Board (Provider side focus) with Quality/Audit Sub- Director of Clinical Audit to provide leadership for provider side quality

! Existing : Clinical Unit Leaders/ Directors and Service managers jointly responsible for quality and resource management

Lakes # # ! Quality managed via heads of departments, nurse consultants & service-based clerical Quality Co-ordinators

! Clinical Council planned to be responsible for quality among other things

Hutt # ! Quality & Risk and Patient Safety Committees report to CEO; Medical Quality and Physicians Audit Committees

! Clinical Audit Registrar appointed

! Clinical Heads of Department responsible for quality with support of service managers

! Support from a Quality Support Group comprising 8.5 currently dispersed quality staff

Nelson/Marlborough # # Existing: About 20 committees each focussing on an aspect(s) of quality – under review Under discussion: an overarching Clinical Council

with quality as one of its responsibilities

Canterbury # ! Clinical Advisory Committee reporting to CEO, membership covers all services in the Operating Division

! Corporate Quality & Risk Manager

! GMs of each division are accountable for quality

! Divisional quality committees (medical incidents/complaints, OSH, infection control, medical appointments, medicines advisory, clinical QA groups)

- Membership: CEO, COO, CMO, CON, cross-section of managers, medical/nursing/allied health staff and a GP

- Responsibilities: various, quality one of a number

! Clinical Improvement Co-ordinators Where two #s are shown there is an existing mechanism which is being reviewed

The board was in the process of reviewing credentialling achievements before proceeding to implement it at Wairau Hospital In Waikato DHB credentialling is also well-established and has become the responsibility of the clinical director in each service division and includes both the unit as well as individual staff

Nine of the DHBs also identified a quality including a risk management focus Within this there was considerable variance The focus on quality management took many forms Seven of the DHBs had established or were working on establishing a clear framework for this This included such things as a developing a vision and/or values,

a set of relevant definitions, quality and risk policies, with links to organisational support and serving as a context within which the quality plans were being developed While all DHBs will have quality plan requirements as part of their contract, only a few mentioned their quality plans during discussions about quality and risk management

All DHBs interviewed had either already been accredited in full or in part eg Marlborough and Waikato, or were aiming for accreditation or re-accreditation in the near future e.g Capital and Coast and Otago Most of those interviewed felt that accreditation itself had made a positive contribution to the growing awareness of quality issues within their organisations However, this view was not uniformly held

Nelson-eg Waikato noted a danger in achieving accreditation without developing a “full and ongoing commitment to quality”

All organisations reported programmes and initiatives related to clinical audit The focus on these varies between DHBs with some appearing much stronger than others For example in Hutt DHB there is a Physicians’ Audit Committee, a registrar has been appointed to drive clinical audit, and each clinical head of department has a job description requiring the promotion of clinical audit with the support of the a service manager

Similarly most DHBs appear to have put considerable effort and work into integration

of clinical and financial management While most DHBs agreed that this was an important part of quality there were some caveats expressed For example, Auckland and Counties-Manukau noted that there is still some discomfort with this among some

of their clinicians especially where resources are constrained A further constraint for some DHBs is making the time available for clinicians to participate (Lakes and Nelson-Marlborough)

Information technology systems are also need to keep pace with this development so that costs can be tracked down to patient level In a number of cases this work had not yet been done hindering the analysis and feedback which could further assist quality initiatives Hutt has achieved this but Auckland and Waikato recognised that they had more work to do in this area On the other hand Nelson-Marlborough was clear that they had some way to go before achieving integration of clinical and financial management Canterbury is still discussing this issue

Almost all DHBs mentioned the implementation of patient safety (adverse incident, incident/accident reporting programmes) Discussion of such projects almost invariably were linked with the need to establish a “no blame” culture” so that

25physicians feel safe discussing mistakes freely and working to prevent their recurrence

26

Table 6.2 Quality initiatives underway in District Health Boards

Quality Initiatives Northland Auckland

Counties-Manukau Waikato Lakes Hutt Capital & Coast Nelson/ Marlborough Canterbury Otago

Integration of clinical and

Less frequently mentioned initiatives include the development of quality standards and guidelines, clinical indicators, benchmarking, medicines advisory projects, and peer review

Other culture changes cited included a growing partnership between clinicians and management as identified by Northland, Auckland and Hutt DHBs Waikato also noted a move away from strictly "business" approach to a culture of quality

Another commonly cited achievement was integrating previously disparate quality efforts into a single coherent quality system as noted by Waikato, Capital and Coast, Otago and Counties-Manukau

Other achievements identified related to individual quality components, for example the implementation of the strong adverse incident system, achieving/working towards accreditation, credentialling progressing well, clinical audit well established, the appointment of staff dedicated to quality, and information technology developments allowing for cost monitoring at patient level

Factors that facilitated quality development:

! the experience of accreditation leading a much greater awareness of quality

! appointment of specific staff whether with a specific quality focus (eg Hutt) or specific clinical staff (eg clinical nurse directors appointed at service level in Counties-Manukau)

! the ability to provide resource tools and incentives (eg Hutt which has invested money in education and training, and quality related videos, manuals, journals etc for staff use)

! the ability to integrate clinical and financial management

! past adverse events “opening up” the need to develop new responses and new organisational cultures

Factors seen as hindering progress with quality:

! resource constraints impinging on the integration of clinical and financial management

! the difficulties in making time for clinicians to participate in management and quality initiatives in some DHBs

! shortage of leadership skills

! past adverse events leading to mistrust between clinicians and management

! the lack of a shared understanding of quality i.e what it means to the

organisation, and what methods are available to improve quality

! not making full use of the information available, eg incident / complaint / patient satisfaction information

! lack of integration of quality planning into the service planning process

29

Table 7.1 District health board quality achievements

District Health Board Achievements in quality

Northland ! Changing culture – clinicians now more open to discussing “mistakes” and developing ways of preventing them

! Partnership between clinicians and management

! Employment of clinical co-ordinators to improve clinical documentation Auckland ! All hospitals and Mental Health and Community Services accredited twice

! Established quality structure supporting multidisciplinary approach and focus on no blame culture

! Credentialling established

! Partnership between clinicians and managers at service level with increasing medical leadership in quality activities Counties-Manukau ! One coherent quality structure ensuring co-ordination

! Twice accredited

! Strong adverse incidents system linked with parallel complaints processing and resolution

! Developing a “learning organisation” with a culture of “safety”

Waikato ! Moving away from a strictly “business” approach to a culture of quality in an environment of “safety and trust” for clinicians

! Recognition of the need for and developing a single coherent quality system, with protocols, pathways and guidelines

! Credentialling well established Lakes ! Plan for integrating accountability for quality and clinical activities developed and under discussion

! Trialled new Hospital and Disability Sector Standards, received commendation for their efforts Hutt ! Gradual culture change leading to current staff “buy in” and “bottom up” initiatives

! Greater awareness of quality issues, accreditation processes built on earlier organisation work

! Increasing focus on clinical audit and appointment of Registrar in Clinical Audit

! IT developments allowing for the monitoring of costs at patient level Capital & Coast ! Consultation document and ensuing discussion on the integration and co-ordination of existing activities, potential benefits

and a culture change

Nelson/Marlborough ! Strong progress on credentialling

! Good audit programmes in most departments

! Two rounds of accreditation have developed a strong awareness of and interest in quality, especially among nursing staff

! Iwi networking established and working well

! Well developed medicines advisory initiative Canterbury ! Strong structural support for some aspects of quality

Otago ! An integrated quality support structure in place

! A quality framework has been established with a quality plan

30

! Credentialling making very good progress and expected to be completed November 2001

The establishment of CMO/A and CNO/A positions at the top executive level of a DHB,

on the provider side, has provided an important, and in many cases, new avenue for clinical advice to be provided at the highest levels of management In some DHBs this advice has provided directly through to the Boards and/or the hospital advisory committee Some CMO/As saw their continued clinical involvement as being important

to their credibility to represent medical interests at executive level rather than being seen

as just part of management

There is also increasing involvement of allied health leadership in clinical advisory functions For example within Waikato DHB allied health staff have been appointed widely as part of the multidisciplinary clinical teams in all divisions and provide clinical advice at all levels in the organisation

It was also noted by some CMO/As and CNO/As that this advisory function should extend beyond just the provider side to the whole DHB However some DHBs have established, or are establishing, separate clinical advisory functions for their contracting/funding arms

CMO/As and CNO/As were also seen to have a key role in leading quality initiatives within DHBs They were key participants in clinical advisory committees, promoting credentialling, clinical audit and handling reportable events

A wide range of clinical advisory committees and groups had been formally established within DHBs to provide not only clinical advice and but also to drive quality initiatives Some of these were well established and had played a key part in the quality improvement process, eg in Counties-Manakau Others were still relatively new and were developing membership and roles which were beginning to address quality strategies

It was repeatedly noted that, although most DHBs have medical and other staff associations, the importance of these is seen to be diminishing This is seen to be a direct consequence of an increasing involvement of clinical staff in devolved clinical service arrangements and the growing partnership between management and clinicians

However as noted elsewhere in this report there are widely varying views about how far this partnership has progressed There is a sense of disempowerment and disenfranchisement amongst some clinicians, despite the clear government commitment to a collaborative model

9.1 Education and training programmes

Most DHBs had education and training programmes supported by their human resources departments For some it was a requirement that clinical leaders participate in programmes However a key limiting factor was the pressure on clinical leaders with their joint clinical and management responsibilities Programmes such as those provided

by the Health Leaders Network were being supported but were seen to be very expensive and Australian based

An interesting example of a DHB commitment to training was found in Hutt Valley DHB From ‘organisational savings’ of $3 million a sum of $200,000 had been set aside for professional development and research, including leave and continuing education This may be one of many examples of the incentives to achieve clinical savings which could both benefit quality and achieve further cost savings

9.2 The need for clinical leadership development

There was almost universal recognition of the need for clinical leadership development along with other leadership development activities It was also recognised that is considerable value in bringing together a range of leaders from different disciplines, geographic areas and service divisions, such as primary and secondary, to build a new leadership culture

A number of key people recalled the Health Services Management Development Unit of the early 1990s as an appropriate model, which might be restored However a broader role would be needed inclusive of clinical leaders and the broad range of sectors now coming within the scope of the DHB system

Table 10.1 Summary of statements by DHB is about clinical governance

DHB Stage of clinical governance

Northland Term not specifically used but process being established and seen to

be alive and growing Auckland Being adopted as a term and based upon the UK definition Is inclusive

of all clinical quality programmes Includes financial management Counties Manakau Definition modelled on the UK and formally adopted as a policy and

strategy Is strongly supported as are processes involved Waikato Adopted UK definition Formal commitment to clinical governance The

quality plan is based upon a clinical governance framework Lakes No policy as yet but there is a clear commitment to it as shown by

various activities involving clinicians in quality developments Hutt Valley The term is not used but the quality strategy is a model of clinical

governance at work Capital and Coast The term has not been adopted by the DHB although many of the

organisational developments are consistent with clinical governance Nelson/Marlborough Definition and process not yet established

Canterbury No formal policy as yet adopted but the term is being increasingly used

in quality discussions Otago No formal policy but the term is widely used in discussions and policy

statements about quality developments

Clinical governance is a process largely driven by clinical values and aspirations, with clinical leadership playing a strong part in this process Also of importance, and in key contrast to the UK model, is that clinical governance is widely seen to be inclusive of resource management

Furthermore and again in contrast to the top-down UK model clinical governance is driven much more from the ‘middle-up’, ie by clinical leadership

11.1 Information sources: tensions and limitations

As stated earlier, this project presents the results of a scan of a selected number of DHBs Funding and time constraints precluded a more detailed review The authors therefore have reservations about the nature and quality of the information drawn upon This review is based on information supplied by top management and clinical advisers, complemented by follow-up discussions, both personally and by telephone

The views presented, therefore, may not be representative of others in the organisation especially given the ‘conflict of cultures’ referred to below Uncertainties remain as to how far plans for quality initiatives have been successfully implemented Discussions with clinical leaders and clinicians generally indicate that perceptions of relationships and progress vary widely between different levels within the DHB organisation Some clinicians, perhaps with ‘axes to grind’, have expressed views which differ markedly from those of top management

Recent editorials in the New Zealand Medical Journal have taken a negative line with regard to governance and management cultures although the views expressed appear to apply largely to Canterbury DHB (Bagshaw et al, 2001) A study of clinical and management staff in Auckland and Wellington hospitals by Sage et al (2001) showed wide differences in attitudes between clinicians and managers Clinical leaders occupied

an intermediate position in their attitudes towards accountability issues

Nevertheless the views of CEOs, and other key people within DHBs, are important They represent a commitment to, if not as yet actual achievements, in quality improvement Furthermore there is a level of consistency in what has been presented showing a significant trend towards improved relationships and in clinical quality which appears to be substantially more advanced than even 12 months ago It is clear that some DHBs are well ahead of others in building a partnership culture

What is needed to complement this review is more detailed studies of the actual roles and responsibilities of both clinical and management leaders within selected DHBs This would assist in clarifying the nature and extent of progress towards better relationships, the potential and actual impact upon continuing quality improvements and the expanding role of clinical leadership in this progress

11.2 Devolution of decision making

This review has documented a clear and continuing trend towards devolution of making to clinical groupings Again the extent to which this is progressing varies widely between DHBs The motivation to devolve varies between DHBs and between management and clinicians

decision-In general it appears that the interests of both managers and clinicians are advanced with devolution For managers, this means involving clinicians in decision making about priorities and accountability for financial management For clinicians, it means having the power to shift resources from less to more important needs Only clinicians are in a

position to know whether or not foregoing a particular investigation, drug or extra days of inpatient care would impair quality and whether the resources so saved would be better spent in other service provision

In other words, quality clinical decision making necessarily involves decisions about the use of resources Given the wide variability in such decision-making and increasing evidence that better quality may not be associated with higher expenditure, the potential for quality outcomes at lower costs could be considerable (Wright et al, 2001) Real devolution to clinical groupings is the first step in securing such gains

This strategy, however, implies devolution not only of direct costs but also of clinical support services, eg laboratory, radiology, operating theatre, etc It also involves indirect costs such as overheads use of beds, associated hotel services and capital costs As yet only a minority of the DHBs studied had progressed to devolution of either clinical support services or overheads

The reasons for this remain unclear, and they were not explored in detail It is in part due

to the quality of information systems involved and the lack of experience of clinical groups in managing the wider range of resources involved There is also concern about the potential impact upon support services of such complete devolution There is also continuing debate about devolution of revenue as compared with costs, an issue which should be resolved with the move to population-based funding and hence removal of the disincentives associated with revenue type funding

11.3 Towards a successful nursing organisation

This review has also shown that there is progressive, if tentative, devolution of nursing resources, including budgets, to service groupings (Section 5.3) Moves towards this devolution are occurring in other countries such as Australia However the issues are complex and the whole process is subject to ongoing debate Advantages of devolution may be summarised as;

! nurses becoming fully recognised as members of health care teams

! the integration of patient care within a multidisciplinary settings, important in both long-term care services and acute care

! the ability to e manage all aspects of care effectively, including nursing, within a service division, especially with nursing being the largest single item within a service budget

! the ability to shift resources, including nursing, within a service budget to ensure the best use of resources

! flexibility in the use of nursing services between hospital and community, eg

midwives, paediatric intensive care and renal dialysis nurses providing home care

! the development of specialised care nursing as part of the clinical team

These advantages are likely to become more important with the development of the DHB system and moves towards community-based care and service integration including the integration of government and the non-government services

However there may be important disadvantages associated with devolution These

include;

! subservience of nursing skills and perspectives to medical and managerial dominance

! a possible weakening of the overall influence and professional contribution of nurses within the organisation

! a lack of overview caused by limited opportunities for professional networking

! a lack of nursing leadership and role modelling of leadership restricting the

development of innovative nursing practice and sharing of nursing knowledge

! a lack of a nursing career structure with nurses tending to move into service

management positions where they no longer directly influence the development of nursing

As documented in this review, and from other sources, these disadvantages may at least

in part be overcome through;

! firm leadership from the DON, or equivalent, bringing a nursing perspective into the top management team and providing overall nursing leadership throughout the DHB

! the DON promoting the role of nursing throughout the organisation and close

working relationships between nurses and other clinicians

! the appointment of nursing directors to the service and sub-service levels in full partnership with the management team at this level, while maintaining clear links to the DON

! the DHB having an organisation-wide policy in place to ensure that the nursing role is valued

! a system of nurse consultants working with service divisions to promote and assess nursing development and integration co-ordinated or facilitated by a DON

! flexibility in the use of the nursing workforce with nursing distribution after regular hours coming under the DON

The success of devolution therefore depends upon two key factors;

! the DHB having an organisation-wide policy which acknowledges and promotes nursing as a key service component in partnership at all levels including at the

executive level

! finding the right person to fill the role of the DON

11.4 Review of quality developments –incentives, achievements

This review has shown that all DHBs are making significant efforts to improve clinical quality All have either a formal structure and process in place for quality improvement

or have plans for such establishment Much discussion is currently under way about the best forms of structuring quality processes and how they should be organised, managed and funded

DHBs also report a wide range of quality initiatives, either planned or under way At organisational level there is increasing commitment to accreditation which, especially

with the new format, is seen to be an important stimulus to overall quality improvement There is wide and increasing support for:

! credentialling of medical staff (from both medical staff and management)

! quality and risk management processes

! clinical audit

Other developments appear to be less well advanced

However, as indicated above, there are uncertainties in the information provided as to the

gap between planning and implementation DHB quality managers, although in general

feeling that their activities are now more valued and recognised, are also constrained as to what can be achieved with funding limitations There are uncertainties about who is actually accountable for quality activities and the relationship between quality departments and clinical services It appears that quality departments are now being seen, perhaps appropriately, in a support role to clinical service divisions which, with their increasing accountabilities, are now assuming a more direct role inquality management

An important development has been the development of structures and processes to ensure integration of quality initiatives within DHBs Integration is being achieved through quality boards, committee and groups

Despite important developments in clinical quality there is a remarkable lack of sharing

of this experience and the lessons learnt Relatively little appears to have been done to document or evaluate quality achievements in DHBs As far as is known this is the first attempt to bring this experience together and provide an overview of these important

developments

There is a serious lack of evaluation in the New Zealand health ‘culture’ a concern noted

by the National Health Committee (NHC) document ‘Safe Systems Supporting Safe

Care’

11.5 Clinical leadership – a new role for clinicians

This review, along with other reports in this trilogy, has noted the growing importance of clinical leadership as a critical factor in promoting clinical quality Clinical leadership may be defined as leadership by clinicians of clinicians The term clinician in this context means all health professionals including doctors, nurses, midwives, therapists and allied health professionals involved in direct patient care Clinical leaders may come from any of these disciplines

Clinical leaders are those who still retain a clinical role for a proportion of their time This leadership may be found within DHBs at three levels At the top executive level, and reporting to the CEO and/or COO, CMO/As and CNO/As bring a medical, nursing and broader clinical perspective into executive decision-making

In some cases CMO/As retain a part time clinical responsibility which they see as necessary for acceptance by their clinical colleagues In other words they are still clinicians even if a part of top management They have not, as did previous ‘medical

in a centralised nursing management model

At the second level are those who are clinical leaders or directors for an overall service level, ie medical, surgical, mental health Accountability at this level is significant and demanding, may occupy up to 5/10ths time and is seen to be in a relatively formalised relationship with management This partnership may include both medical and nursing leadership

At the third level, are subdivisions of medicine, surgery, mental health, eg cardiology, respiratory medicine, orthopaedics, child psychiatry for example, where clinical leadership responsibilities may occupy 2/10ths time, be less formalised and perhaps less developed Again the partnership at this level may include both medical and nursing leadership, in partnership with non-clinical service managers

As discussed below, effective clinical leadership at any of these levels requires a partnership with management Clinical leadership is more than just an accommodation between clinical leadership and management Clinical leaders are required to walk an uneasy path between claims for autonomy by their clinical ‘rank-and-file’ colleagues at the same time as developing a relationship with management and its demands for clinical accountability

11.6 Towards a convergence of governance/management and clinical cultures

The study by Sage et al (2001) of management and clinical staff in Auckland and Wellington hospitals showed a wide divergence in attitudes towards accountability issues However this study has demonstrated that, in almost all DHBs, there is a willingness, intention and actuality in building a partnership between governance/management and clinical cultures In some DHBs this partnership is well-established a notable example being Counties-Manakau where there was little, if any, conflict arising from the commercially-oriented reforms of the 1990s In others, eg Capital and Coast, where there was serious conflict, specific recent efforts have been made to build up this partnership with progress being evident although not necessarily well accepted as yet

Not surprisingly, with the very public conflicts of the 1990s leading to the Stent report, Canterbury DHB is perhaps the least advanced in building up this partnership The ‘clash

of cultures’ experienced at that time led to a serious breakdown in relationships (Hornblow, 1997) A process of recovery from this conflict has only recently been established and will require a willingness and commitment to build a partnership from both ‘sides’

However this partnership requires a shift in both governance/management as well as

clinical cultures The required shift in the governance/management culture requires the

following;

! a full and unambiguous commitment to the ‘bottom line’ of the organisation being better health outcomes for patients and communities as required in the New Zealand Health Strategy

! a recognition that resource/financial management is a means to achieve this, not

! clear responsibilities and accountabilities for decision-making and clinical quality

! provision of reliable and valid information relating to clinical quality

On the other hand a change in the clinical culture is required in building this partnership

On the other hand it will be equally obvious that there are many clinicians who have yet

to embark upon a pathway of convergence Such clinicians hold to traditional, if outdated, notions of individual clinical autonomy and their right to make resource-free decisions which they see as necessary for the benefit of their patients

Clinical leaders may also be at different stages along the pathway, some already building

a partnership with management, others still unsure and perhaps unwilling to be seen by more conservative colleagues to be joining the ‘other side’

However real clinical leadership is not about taking sides It is about bringing clinicians, perhaps reluctantly, to understand that the clinical quality improvements, now being

sought by patients, communities and governments, can only be achieved within an organisation seeking to achieve common goals to which both governance/management and all clinicians are committed

Figure 11.1 Model of the converging relationships between the governance/managerial

cultures and clinical cultures towards a partnership to achieve common goals

A convergence of cultures is also needed within the clinical culture As has been presented in this review, devolution of decision-making to clinical groupings has, to an increasing extent, brought nursing into the clinical team However the extent to which this is occurring varies widely despite an increasing commitment to it

Of equal importance is the need for a convergence in secondary and primary care cultures discussed below under wider DHB responsibilities for quality As has been discussed elsewhere convergence within PCOs is almost total (Malcolm et al, 2001) Clinicians there are also involved in governance Significant improvements in quality are being achieved as a direct consequence of their governance and leadership roles

There may be important lessons to clinicians in secondary care from developments in PCOs Clinical leaders in the latter settings have a much stronger sense of clinical empowerment and even clinical autonomy They have the power, within defined budgets,

to make decisions about priorities and to shift resources from less to more important services for the benefits of their patients and communities